What is the difference between a HMO and PPO?
Under a Health Maintenance Organization (HMO) patients need to choose a PCP from that HMO’s network. Before patients can be referred to or seen by a specialist, patients MUST first be seen by their chosen PCP. A referral from a PCP is required prior to any scheduled visits. Patients who choose to go outside of their HMO network WITHOUT a referral from a PCP may be responsible for the entire medical bill. Under a Preferred Provider Organization (PPO) patients choose doctors and healthcare providers within that PPO’s network. Patients DO NOT need referrals to see a specialist, as long as the specialist is a participating provider in the network. Under a PPO, patients can choose to go outside of their PPO network; however, if patients choose to go outside of their PPO network, they will incur higher out-of-pocket expenses, because out-of-network benefits will apply. Most insurance plans are PPO’s, but patients should verify their plan with their insurance company to be sure.
